Medicare Part D: A First Look at Plan Offerings in 2016

During the Medicare open enrollment period, which runs from October 15 to December 7 each year,

beneficiaries have the opportunity to enroll in a plan that provides Part D prescription drug coverage, either a

stand-alone prescription drug plan (PDP) as a supplement to traditional Medicare, or a Medicare Advantage

drug plan (MA-PD), which provides all Medicare-covered benefits including prescription drugs. Of the nearly

40 million beneficiaries enrolled in Part D plans, about 6 in 10 are in PDPs and the rest in MA-PDs.

This issue brief provides an overview of the 2016 PDP marketplace, focusing on key changes from 2015, based

on our analysis of data from the Centers for Medicare & Medicaid Services (CMS). , In 2016, the typical

Medicare beneficiary will have a choice of more than two dozen PDPs. Many will see higher premiums and

deductibles if they remain in their current plan. As in the past, Part D enrollees need to consider that their plan

may require coinsurance, rather than flat copayments, for brand-name and specialty drugs, and differential

cost sharing for prescriptions depending on their choice of pharmacy. These factors, as well as which drugs are

included on a plan's formulary, may affect out-of-pocket costs as much as premiums. Other highlights include:

In 2016, beneficiaries in each region will have a choice of 26 PDPs, on average, down by 4 from 2015.

The average PDP premium (weighted by 2015 plan enrollment) is projected to increase by 13 percent from

2015 to 2016, from $36.68 to $41.46 per month. Even if a number of beneficiaries switch or are reassigned to

lower-premium plans, the average premium increase for 2016 is likely to be the largest since 2009.

More than one-third of the 11.2 million PDP enrollees who do not receive Low-Income Subsidies (LIS) would

pay premiums of $60 or more per month in 2016 if they stay in the same plan.

Nearly 4.4 million of these enrollees not receiving the LIS face a premium increase of at least $10 per month

in 2016 if they stay in the same plan.

Two-thirds of all PDPs will have deductibles in 2016, a higher share than in previous years. A growing share

of PDPs will impose the maximum deductible allowed by law, which increased from $320 in 2015 to $360 in

2016, the largest increase in the deductible since the start of the program.

Most PDPs charge coinsurance, rather than flat copayments, for non-preferred brand-name and specialty

drugs, which could lead to higher out-of-pocket costs for those who use high-cost drugs.

Nearly all PDPs (84 percent in 2016) use tiered pharmacy networks, with lower cost sharing in selected

network pharmacies and higher cost sharing in other network pharmacies, a significant increase from just a

few years ago when only a small share of plans used this type of preferred pricing (7 percent in 2011).

Beneficiaries receiving the LIS will have access to 7 plans for no monthly premium in 2016, on average, fewer

than in any past year. About 1.9 million LIS enrollees who are slated to be in PDPs where they will pay

premiums must switch plans or be reassigned by CMS in order to have premium-free coverage in 2016.

In 2016, beneficiaries across the country continue to have a substantial number of Part D plan choices.

The average beneficiary will have a choice

of 26 PDPs in 2016, down from 30 in 2015

and 55 at the peak in 2007 (Figure 1).

Beneficiaries will also have access to 16

Medicare Advantage prescription drug

plans, on average.

The number of PDPs per region in 2016

will range from a low of 19 PDPs in the

Alaska region to a high of 29 PDPs in the

Pennsylvania/West Virginia region

(Figure 2; Appendix 1, Table A1). The

number of plans is lower in all but one

region (Pennsylvania/West Virginia)

compared to 2015; there are five fewer

PDPs in Alaska, Florida, and Illinois in

2016.

A total of 886 PDPs will be offered

nationwide in 2016, down by 11 percent

from the 1,001 PDPs offered in 2015 and

the lowest number of PDPs in the

program’s history (Figure 3). The total

number of PDPs in 2016 represents less

than half the number offered at the peak

level in 2007 of 1,875 plans. The lower

number of plans reflects both the

cumulative effect of mergers among plan

sponsors and the response to CMS policies

that encourage plan sponsors to eliminate

low-enrollment plans and to drop multiple

PDPs that are not meaningfully different from each other.

In 2016, there are 11 plan sponsors offering 23 PDPs on a national or near-national basis. The number of

national or near-national plan sponsors is down from 18 in 2009, as a result of corporate acquisitions and

some firms exiting the market after not achieving a substantial market share. In addition, more sponsors are

offering two PDPs, whereas it was more common to offer three in the program’s early years.

In July 2015, the PDP sponsor Torchmark Corporation was placed under a sanction that banned marketing

activities and new enrollments. Its PDPs, marketed under the United American name, have 208,000

enrollees in 91 PDPs across all regions in September 2015.

Figure 2Figure 2

27

26OR, WA

2828

26IA, MN, MT, NE,

ND, SD, WY

25

27

28

26 27

26 28

27

28

2728

22

2419

26

25

25NJ

21HI

22

26 27

26CT, MA, RI, VT

27ME, NH

28

27AL, TN

NOTE: PDP is prescription drug plan. Excludes plans in the territories. Includes 91 plans under CMS sanction and closed to new enrollees as of September 2015. SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2016 PDP landscape source files.

Number of PDPs, by Region, 2016

28ID, UT

24DE, DC, MD

29PA, WV

28IN, KY

19-24 plans 25-26 plans 27 plans 28-29 plans6 regions 10 regions 8 regions 10 regions

Average Number of PDPs Per Region = 26

Figure 1Figure 1

42

55 5450

46

33 31 3135

3026

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016NOTE: PDP is prescription drug plan. Estimates are beneficiary weighted. Excludes plans in the territories; includes plans under CMS sanction and closed to new enrollees.SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2006-2016 PDP enrollment, crosswalk, and landscape source files.

Average Number of PDPs Offered to Medicare Beneficiaries, 2006-2016

For 2016, 31 new PDPs are entering the

market, and 146 PDPs are exiting the

program. (See Appendix 2 for more detail

on market dynamics.)

Two new sponsors are entering the PDP

market in 2016: Magellan Rx America,

offering PDPs in 20 regions, and

QualChoice Advantage, offering a PDP

only in Arkansas.

Among the 146 exiting plans, 143 are

offered by sponsors that offer other PDPs,

and enrollees in most of them (137 of 143)

will be automatically assigned to another

PDP offered by that sponsor. This process

should ensure a seamless transition and minimize disruption that would otherwise result from plan

terminations. The other 3 exiting PDPs are offered by sponsors (each operating in a single region) leaving the

market entirely

The national average monthly PDP premium is expected to increase for 2016, marking a significant departure

from recent years when premiums were essentially flat. Even if a number of beneficiaries switch or are

reassigned to lower-premium plans, effective in January 2016, the average premium increase for 2016 is likely

to be the largest amount in any year since 2009.

The projected average monthly PDP premium for 2016 will be $41.46 (weighted by September 2015

enrollment, assuming beneficiaries remain in their current plan) (Figure 4). This is a 13 percent projected

increase ($4.66) from the weighted average monthly premium of $36.68 in 2015, and a 60 percent increase

from $25.93 in 2006, the first year of the

Medicare Part D drug benefit. As a point of

comparison, since 2006, the medical care

consumer price index (CPI) has increased

34 percent and the CPI for all items has

increased 18 percent.

In prior years, the average premium after

the end of the open enrollment period has

been 4 percent to 5 percent lower than the

projection made during the open

enrollment period, due to existing

enrollees switching to a lower premium

plan, new enrollees choosing low-premium

plans, and reassignments of some LIS

Figure 3Figure 3

1,429

1,875 1,8241,689

1,576

1,1091,041 1,031

1,169

1,001886

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

NOTE: PDP is prescription drug plan. Excludes plans in the territories. Total for 2016 includes 91 plans under CMS sanction and closed to new enrollees as of September 2015.SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2006-2016 PDP landscape source files.

Number of PDPs, 2006-2016

Figure 4Figure 4

$25.93$27.39

$29.89

$35.09$37.25 $38.29 $37.78 $38.54 $37.75 $36.68

$41.46

$0

$5

$10

$15

$20

$25

$30

$35

$40

$45

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

NOTE: PDP is prescription drug plan. Average premiums are weighted by enrollment in each year (September 2015 enrollment used for 2015 and 2016). Excludes plans in the territories. SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2006-2016 PDP enrollment and landscape source files.

Weighted Average Monthly Premiums for PDPs, 2006-2016

2006-2016: 60% increase

2015-2016:

13% projected

increase

Projected

beneficiaries to cheaper plans. For example, the average premium in February 2015 was $37.20,which is

about 4 percent ($1.63) below the projected premium of $38.83 calculated prior to enrollment changes.

Applying a similar adjustment to our projected premium for 2016 suggests that the premium increase, after

open enrollment, is likely to be lower, but still larger than in any year since 2009.

For PDPs offering only the basic benefit, the 2016 weighted average premium is projected to be 8 percent

higher in 2016 than in 2015 (based on current enrollment patterns), whereas premiums for enhanced PDPs

are projected to rise by about 17 percent.

A growing share of PDP enrollees are paying premiums that are well above the national average.

In 2016, over one-third of PDP enrollees

not receiving the LIS (36 percent) are

projected to have premiums of at least $60

per month if they stay in their plans—a

substantial increase from the 10 percent of

enrollees paying premiums at this level in

2015 (Figure 5). Among them, nearly

400,000 are projected to pay premiums of

at least $100 per month. By contrast, 14

percent of these PDP enrollees are

scheduled to pay premiums of less than

$20 per month.

CMS reported that the average premium for

standard Part D coverage offered by PDPs

and Medicare Advantage drug plans will

“remain stable” at an estimated $32.50 in 2016. The higher premium reported here is based on PDPs only,

including PDPs offering both basic and enhanced coverage. Enhanced plans typically have higher premiums

than basic PDPs. Our estimate does not assume any voluntary switches by beneficiaries and reassignments by

CMS of Low-Income Subsidy enrollees to

different plans, nor do we make any

assumptions about plan choices made by new

enrollees in 2016.

Underneath these national trends, premium

changes for individual PDPs from 2015 to

2016 vary widely (Figure 6).

Among the 11.2 million Part D

PDP enrollees who are responsible for

paying the entire premium (which excludes

LIS recipients), most (83 percent) are

projected to have a higher premium in

Figure 6Figure 6

18%

13%

2%

4%

52%

44%

28%

39%

Increase of$10 or more

NOTE: PDP is prescription drug plan. LIS is Low-Income Subsidy. Analysis excludes enrollees for whom CMS provides no crosswalk between their 2015 and 2016 PDPs.SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2015-2016 PDP enrollment, crosswalk, and landscape source files.

Distribution of Changes in Monthly Premiums for PDP Enrollees Between 2015 and 2016If Enrollees Do Not Switch Plans Between 2015 and 2016

Decrease of $10 or more

Decrease of less than $10

Increase of less than $10

Non-LIS enrollees (n=11.2 million)

All PDP enrollees (n=19.3 million)

Figure 5Figure 5

13% 14%

35% 30%

43%

20%

10%

36%

2015 2016

More than $60

$40-$60

$20-$40

Less than $20

NOTE: LIS is low-income subsidy. PDP is prescription drug plan. Analysis excludes enrollees for whom CMS provides no crosswalk between their 2015 and 2016 PDPs. 2016 distribution assumes no plan changes during the open enrollment period.SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2015-2016 PDP enrollment, crosswalk, and landscape source files.

Distribution of PDP Enrollees By Monthly Premium, 2015 (Actual) and 2016 (Projected)Excluding Enrollees Who Receive Low-Income Subsidies

2015 Non-LIS PDP Enrollment = 11.2 million

2016 if they stay in their current plans, including 4.4 million (39 percent) who are projected to have a

premium increase of at least $10 per month. Conversely, nearly half a million (448,000) are projected to

experience a premium decrease of $10 or more.

Taking into account all PDP enrollees, including the LIS enrollees whose premiums are partially paid by the

government, 80 percent are in plans in which premiums are projected to rise in 2016 if they stay in their

current plans; this includes 28 percent in plans that will have an increase of $10 or more in their monthly

premium in 2016 assuming no enrollment changes. By contrast, 2 percent of all PDP enrollees are in plans

projected to have a premium decrease of $10 or more.

Changes to premiums from 2015 to 2016,

averaged across regions and weighted by

2015 enrollment, vary widely across some of

the most popular PDPs (Figure 7). These

variations reflect factors such as higher

premiums in older plans and substantial

geographic variations. Although variation in

benefits is also a factor, premium variation

persists even among PDPs that offer benefits

actuarially equivalent to the basic benefit

defined in law.

Average premiums for seven of the eight

largest PDPs will increase for 2016. Five of

these seven PDPs will have larger average

percentage increases than the national

average. Average premiums for three of these PDPs are projected to increase by at least 20 percent in 2016.

The highest increases, in percentage terms, are for Humana Enhanced PDP, with 1.1 million enrollees in

2015, and AARP MedicareRx Saver Plus, with 1.4 million enrollees. On average, premiums for both PDPs will

rise 25 percent (from $52.86 to $66.25 for Humana Enhanced and from $28.13 to $35.23 for AARP

MedicareRx Saver Plus). The average monthly premium for the PDP with the most enrollees in 2015, AARP

MedicareRx Preferred, with 3.5 million enrollees, will increase by 21 percent between 2015 and 2016, from

$50.19 to $60.79.

By contrast, enrollees in one of the largest PDPs will experience a modest decrease in their monthly premium

if they stay in the same plan. The average monthly premium for SilverScript Choice will decrease by 2

percent ($22.56 in 2016 versus $23.13 in 2015).

Enrollees in some of the most popular PDPs could see bigger or smaller premium increases than the national

average, depending on the region where they live.

UnitedHealth’s AARP MedicareRx Preferred PDP is raising premiums by as little as 9 percent (in

Oregon/Washington) but as high as 37 percent (in Alaska) (Figure 8). The range is even greater for CVS

Health’s SilverScript Choice PDP, which is reducing premiums by as much as 36 percent (in Arkansas) and

increasing premiums by as much as 24 percent (in Florida).

Figure 7Figure 7

Name of PDPType of plan

First year offered

2015 Enrollment (in millions)

Weighted Average Monthly Premium1 % Change

# % of TotalFirst year 2015 2016

2015-2016

First year-2016

AARP MedicareRxPreferred

Enhanced 2006 3.49 18.3% $26.31 $50.19 $60.79 +21% +131%

SilverScript Choice Basic 2006 3.30 17.3% $28.32 $23.13 $22.56 -2% -20%

Humana Preferred Rx Basic 2011 1.71 9.0% $14.80 $26.45 $28.39 +7% +92%

Humana Walmart Rx Enhanced 2014 1.51 7.9% $12.60 $15.67 $18.40 +17% +46%

AARP MedicareRxSaver Plus

Basic 2013 1.39 7.3% $15.00 $28.13 $35.23 +25% +135%

Humana Enhanced Enhanced 2006 1.14 6.0% $14.73 $52.86 $66.25 +25% +350%

Cigna-HealthSpring Rx Secure

Basic 2006 0.93 4.9% $35.05 $30.84 $36.39 +18% +4%

WellCare Classic Basic 2007 0.87 4.6% $15.80 $31.05 $32.06 +3% +103%

TOTAL 19.33 100% $25.93 $36.68 $41.34 +13% +59%

NOTE: PDP is prescription drug plan. Plan names can change from year to year; plans are designated the same if they have the same contract/plan ID. 1Average premiums are weighted by enrollment in each region for each year. SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2006-2016 PDP enrollment, crosswalk, and landscape source files.

Monthly Premiums for PDPs with Highest 2015 Enrollment

Monthly premiums for the most popular

PDPs available since the start of the Part D

program in 2006 have changed in different

ways.

The average premium for Humana PDP

Enhanced, with 1.1 million enrollees in

2015, is more than four times higher than

it was in 2006, having increased from

$14.73 to $66.25. Of the eight most

popular PDPs, this plan is projected to

have the most expensive monthly premium

in 2016.

The average premium for UnitedHealth’s

AARP Preferred MedicareRx PDP, the PDP

with the most enrollees in 2015 (3.5 million), has more than doubled since 2006, from $26.31 to $60.79 in

2016.

By contrast, the monthly premium for SilverScript Choice, operated by CVS Health, with 2.5 million

enrollees in 2015, is 20 percent lower in 2016 ($22.56) than it was in 2006 ($28.32).

Average PDP monthly premiums, weighted by 2015 enrollment, will vary widely in 2016 across regions, along

with the change in premiums from 2015 to 2016.

Average PDP premiums will range from

$29.70 per month in the New Mexico

region (one of only three regions with an

average under $35) to $49.61 per month in

New Jersey and $45.31 in Florida

(Appendix 1, Table A2).

Premium changes from 2015 to 2016 vary

considerably by region. For example,

average premiums in Arkansas are

projected to fall by about 1 percent,

whereas average premiums will be at least

20 percent higher in Arizona and Florida

(Figure 9).

Average and plan-level premium amounts do not take into account the income-related Part D premium that

took effect in 2011 for Part D enrollees with higher annual incomes ($85,000/individual and

$170,000/couple). Established by the Affordable Care Act of 2010 (ACA), the income-related Part D premium

Figure 9Figure 9

+7% OR, WA

+13%+16%

+3%IA, MN, MT, NE,

ND, SD, WY

+15%

+11%

+17%

+24% +12%

+14% +10%

+17%

+16%

+16%+11%

+13%

+7%+19%

+12%

+7%

+17% NJ

+17%HI

-1% +6%

+13%CT, MA, RI, VT

+17%ME, NH

+19%

+16%AL, TN

NOTE: PDP is prescription drug plan.SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2015-2016 PDP enrollment, crosswalk, and landscape source files.

Change in Weighted Average Premiums for PDPs, by Region, 2016

+9%ID, UT

+15%DE, DC, MD

+9%PA, WV

+11%IN, KY

National Average = +13%

1% decrease

3-9% increase

10-15% increase

16-25% increase

1 region 7 regions 13 regions 13 regions

+21%FL

+13%

Figure 8Figure 8

37% (AK)

24% (FL)29% (FL)

9% (OR/WA)

-36% (AR)

-18% (AR)

21%

-2%

7%

-50%

-40%

-30%

-20%

-10%

0%

10%

20%

30%

40%

50%

AARP MedicareRx Preferred

SilverScript Choice Humana Preferred Rx

NOTE: PDP is prescription drug plan. State abbreviations included in parentheses correspond to regions with highest and lowest percentage change.SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2016 PDP enrollment, crosswalk, and landscape source files.

2015-2016 Percentage Change in Monthly Premiums for Top Three PDPs by 2015 EnrollmentAverage and Highest-Lowest Percentage Change in Premiums By Region Highest

percentage change,

2015-2016, by region

Average percentage

change, 2015-2016

Lowest percentage

change, 2015-2016, by region

2016 average premium: $60.79

2016 average premium: $22.56

2016 average premium: $28.39

requires higher-income enrollees to make an additional payment to the government for Part D coverage,

regardless of the plan selected. In 2016, the monthly surcharge will range from $12.70 to $72.90, depending on

income, in addition to the monthly premium payment for the specific Part D plan. Nearly 6 percent of Part D

enrollees are expected to make these additional payments in 2016. Under current law, the income thresholds

are not indexed to increase annually until 2020, meaning that by 2019, a projected 8 percent of Part D

enrollees will pay income-related premiums.

In 2016, for the second year in a row, all Part D PDPs will offer an alternative benefit design to the defined

standard benefit, which has a $360 deductible in 2016 and 25 percent coinsurance for all covered drugs. Some

plans modify or eliminate the deductible, and all PDPs use some type of varying cost-sharing tiers for covered

generic and brand-name drugs.

The standard (maximum) Part D deductible is increasing by $40 in 2016, the largest one-year increase since

the program began. It is adjusted each year by a statutory formula based on the annual percentage increase in

average per capita aggregate expenditures for covered Part D drugs. Other amounts for the standard benefit

design parameters are increasing as well (see Appendix 3 for the 2006-2016 standard benefit amounts).

Two-thirds of PDPs (67 percent) will

charge a deductible in 2016, up from 58

percent in 2015 (Figure 10). The share of

PDPs with a deductible is the highest ever

in the program. Most PDPs adding

deductibles have relatively few enrollees, so

the share of PDP enrollees facing a

deductible is likely to change more

modestly. Nearly two-thirds of all Part D

enrollees are in plans that are increasing

the deductible for 2016.

Most PDPs with a deductible (53 percent)

will charge the standard $360 amount,

which is also the highest share in the

program’s history. Another 14 percent of all

PDPs have a deductible below the standard amount.

The use of formulary tiers has been common since the program’s beginning in 2006, but for the second year

in a row, all PDPs will use tiered cost sharing. Similar to 2015, most PDPs will use five tiers (two for generic

drugs, two for brand-name drugs, and one for higher-cost specialty drugs).

Over the years, there has been a trend toward the use of coinsurance in place of flat copayments for some

formulary tiers. Coinsurance typically means higher out-of-pocket costs for more expensive drugs, such as

those over $200 per month. Coinsurance has been used by nearly all plans for the specialty tier since 2006,

Figure 10Figure 10

34% 32% 33% 34% 36% 40% 43% 45% 49%44%

53%

8% 8% 8%11%

24% 18% 10% 10% 4% 14%

14%

58% 60% 59% 55%

40% 42%47% 45% 47%

42%33%

Nodeductible

Partialdeductible

Standarddeductible

NOTE: PDP is prescription drug plan. Estimates may not sum to total due to rounding. SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2006-2016 PDP landscape source files.

Share of PDPs, By Deductible Amount, 2006-2016

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

$250 $265 $275 $295 $310 $310 $320 $325 $310 $320 $360

Standard deductible amount:

and that coinsurance cannot exceed 33 percent. For all PDPs, the specialty tier coinsurance is set between 25

percent and 33 percent. In the program’s early years coinsurance was uncommon for other tiers, but in 2016,

over 90 percent of PDPs are using coinsurance for their non-preferred brand tiers; about 40 percent do so

for their preferred brand tiers.

For brand tiers, the typical coinsurance is 20 percent for preferred brands and 40 percent for non-preferred

brands. CMS guidance allows coinsurance for these tiers to be set as high as 25 percent and 50 percent,

respectively. Some PDPs have elected to set coinsurance at these maximum levels.

The coverage gap, or “doughnut hole,” is gradually becoming a less salient feature of the Part D benefit design,

as a result of changes made by the ACA. It will be fully eliminated as of 2020, when beneficiaries will only be

responsible for 25 percent of their total drug costs in the gap. Since 2011, any beneficiary with drug costs high

enough to reach the gap has paid less than the full cost of the price of their drugs. In 2016, manufacturer prices

for brand-name drugs purchased in the gap will be discounted by 50 percent, with plans paying an additional 5

percent of the cost and enrollees paying the remaining 45 percent. Plans will pay 42 percent of the cost for

generic drugs in the gap, with enrollees paying 58 percent. In 2016, the coverage gap begins after an enrollee

incurs $2,960 in total drug spending and ends after an enrollee has spent a total of $4,850 out of pocket (or

$7,515 in total drug costs under the standard benefit). At that point, catastrophic coverage begins, where

enrollees generally pay only 5 percent of drug costs.

Most Part D plans will offer no gap coverage in 2016 beyond what is required by the ACA under the standard

benefit. With all Part D enrollees now getting coverage for a share of their costs in the gap, the value of

additional gap coverage offered by plans will become lower each year until 2020, when the gap is fully closed.

In 2016, about 78 percent of all PDPs will offer no additional gap coverage. This is a small increase from

2015, when 74 percent of PDPs offered no additional gap coverage—meaning a slightly smaller share of plans

will offer some gap coverage beyond what the ACA requires in 2016 than in 2015. One national PDP (First

Health Part D Value Plus) added gap coverage, and one near-national plan (Symphonix PrimeSaver Rx)

dropped gap coverage.

Nearly all PDPs (85 percent) use tiered pharmacy networks. In these networks, enrollees pay preferred (lower)

cost sharing for their prescriptions when they use selected network pharmacies and higher cost sharing in

other network pharmacies.

The share of PDPs with tiered preferred pharmacy networks is down slightly from 87 percent in 2015, but

still a significant increase from just a few years ago when only a small share of plans used this type of

preferred pricing (7 percent in 2011).

The cost implications of tiered pharmacy networks for enrollees vary across PDPs.

For example, among the national and near-national PDPs with tiered pharmacy networks, the AARP

MedicareRx Saver Plus PDP charges a $20 copayment for a preferred brand drug in a pharmacy that offers

preferred cost sharing and $33 in another network pharmacy that does not offer preferred cost sharing. The

Humana Walmart Rx PDP charges a $1 copayment for preferred generic drugs and $4 for non-preferred

generics at a pharmacy with preferred cost sharing, compared to $10 and $33, respectively, at other network

pharmacies where preferred cost sharing is not offered. These differentials are somewhat smaller than in

2015.

In 2016, the total availability of premium-free (benchmark) plans—that is, PDPs available for no monthly

premium to Low-Income Subsidy (LIS) enrollees—will be at its lowest level in the program’s ten years (Figure

11; Appendix 1, Table A3).

In 2016, 226 plans will be available for

enrollment of LIS recipients for zero

premium. This represents a 20 percent

decrease in plans for LIS recipients, or 57

fewer plans than in 2015 and 126 fewer

plans than in 2014.

On average (weighted by enrollment), LIS

have 7 benchmark plans available to them

for 2016, or about one-fourth the number

of PDP choices available overall. All LIS

enrollees retain the option to select other

plans offered in their area, but if they

enroll in a non-benchmark plan, they must

pay a share of the monthly premium.

Of the 226 benchmark plans in 2016, about one in four (57 plans) qualify through the “de minimis” policy—

about the same number as the 54 “de minimis” plans in 2015. Policies adopted by CMS in previous years

make it easier for PDPs to qualify as benchmark plans, including the “de minimis” policy that allows plans to

waive a premium amount of up to $2 in order to retain their LIS enrollees.

Among the 2015 benchmark plans, 72 PDPs have lost their benchmark status due to either higher premiums

in 2016 or to a lower regional benchmark in 2016 (one other exited the market completely). About 742,000

LIS beneficiaries (9 percent of LIS enrollment in PDPs in 2015) are enrolled in these 73 plans, meaning these

beneficiaries may experience some disruption in their coverage for 2016. In 2016, 25 PDPs will newly qualify

for benchmark status: 14 PDPs new to the program and 11 older PDPs (in nine other cases, two benchmark

PDPs were consolidated by the plan sponsor).

The number of benchmark plans available in 2016 will vary by region, from 10 benchmark PDPs in the Arizona,

Idaho/Utah, and Pennsylvania/West Virginia regions to just 2 benchmark PDPs in the Hawaii region (out of 21

PDPs overall) and 3 (of 22) in the Florida region (Figure 12).

Figure 11Figure 11

409483

442

308 307258 252 218

273229

169

157

53

74 75 11379

54

57

409

640

495

308 307332 327 331 352

283

226

De minimis plans*

Benchmark plans

NOTE: PDP is prescription drug plan. Excludes plans in the territories. *De minimis plans can retain Low-Income Subsidy beneficiaries despite exceeding the benchmark premium by up to $2 in 2007, $1 in 2008, and $2 in 2011-2016. SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2006-2016 PDP landscape source files.

Number of PDPs Available Without a Premium to Low-Income Subsidy Recipients, 2006-2016

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

29% 34% 27% 18% 19% 30% 31% 32% 30% 28% 26%

Share of

PDPs:

Benchmark plan availability will decline in

26 of 34 regions between 2015 and 2016,

while one additional benchmark plan will

be available in 3 regions (Figure 13).

Year-to-year changes in most regions are

relatively modest; the largest change is the

loss of seven benchmark plans in the

Hawaii region, after gaining five

benchmark plans for 2015 and losing six

for 2014. As a result of losing this many

benchmark plans, 92 percent of Hawaii’s

LIS beneficiaries are projected to pay a

premium unless they are reassigned or

switch plans. In five other regions,

between 40 percent and 50 percent of LIS

beneficiaries are in this same situation. In

regions where the availability of

benchmark plans is more stable, the share

of affected LIS beneficiaries is much

smaller.

About 1.9 million people—about one in four

LIS beneficiaries (24 percent)—are enrolled

in PDPs in 2015 that will not qualify as

benchmark plans in 2016 (Figure 14).

This group includes 742,000 beneficiaries

who were in benchmark plans in 2015; the

remaining three-fifths (60 percent) of

these beneficiaries are currently enrolled

in non-benchmark plans and thus paid a

premium in 2015.

About 764,000 LIS enrollees will pay

premiums of at least $20 per month and

about 53,000 LIS enrollees will pay

premiums of at least $50 per month if they

do not switch to other PDPs.

The number of LIS beneficiaries who will

potentially pay a premium in 2016 unless

they enroll in (or are switched to)

Figure 13Figure 13

-3

-1OR, WA

----

--IA, MN, MT, NE,

ND, SD, WY

-2

-4

-2

-2 +1

-1 -2

-3

-1

-1-2

--

-3-1

-2

-4

-2NJ

-7HI

-1

-2 -3

+1CT, MA, RI, VT

--ME, NH

-2

-4AL, TN

NOTE: ‘—’ indicates no change in number of benchmark plans.SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2015-2016 PDP landscape source files.

Change in Number of Part D Benchmark Plans, By Region, 2015-2016

-2ID, UT

-1DE, DC, MD

+1PA, WV

-3IN, KY

Decrease of 3-7 plans

Decrease of 1-2 plans

No change (--)

Increase of 1 plan

9 regions 17 regions 5 regions 3 regions

Net Change in Benchmark Plans Across All Regions = -57

Figure 14Figure 14

NOTE: PDP is prescription drug plan. Analysis includes enrollment in PDPs only. Estimates do not sum to total due to rounding. Analysis excludes enrollees for whom CMS provides no crosswalk between their 2015 and 2016 PDPs.SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2015-2016 PDP enrollment, crosswalk, and landscape source files.

Part D Low-Income Subsidy (LIS) Enrollment by Benchmark Plan Status, as of 2016 Open Enrollment Period

Total LIS Enrollment in PDPs in 2015 = 7.9 million

6.1 million

LIS enrollees

(76%)

1.9 million

LIS enrollees

(24%)

2015 plan IS

a benchmark plan in 2016

2015 plan IS NOT

a benchmark plan in 2016

Figure 12Figure 12

5

9OR, WA

64

5IA, MN, MT, NE,

ND, SD, WY

5

6

8

10 8

6 4

5

9

78

8

66

7

7

8NJ

2HI

3

4 4

6CT, MA, RI, VT

9ME, NH

7

8AL, TN

NOTE: Includes “de minimis” plans that can retain Low-Income Subsidy beneficiaries despite exceeding the benchmark premium by up to $2 in 2016. SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2016 PDP landscape source file.

Number of Part D Benchmark Plans, by Region, 2016

Total Number of Benchmark Plans Across All Regions = 226

10ID, UT

9DE, DC, MD

10PA, WV

7IN, KY

2-4 plans 5-6 plans 7-8 plans 9-10 plans6 regions 10 regions 11 regions 7 regions

benchmark plans (1.9 million) is up slightly from the 1.8 million LIS beneficiaries who were in a similar

situation at the time of the open enrollment period for 2015. CMS will reassign those LIS enrollees who were

randomly assigned by CMS to their current plan, and several states will help reassign those enrolled in their

state pharmacy assistance programs (SPAPs). Effective for January 2015, CMS reassigned about one-fifth

of those scheduled to pay a premium. Many other LIS beneficiaries who are currently not enrolled in plans

that will be premium-free in 2016 must switch plans on their own or pay a premium if they remain in their

2015 plan. Those in the latter group will not be automatically reassigned by CMS because in the past they or

someone assisting them made a choice to switch plans. Most affected LIS beneficiaries will receive a letter

from CMS or their SPAP either informing them of their reassignment or reminding them that they can

choose a different plan and avoid paying a premium.

The number of premium-free plans for LIS enrollees offered by the major Part D organizations has fluctuated

substantially over the years.

For 2016, six PDP sponsors will offer benchmark plans in at least half of the 34 regions. No sponsor will

offer benchmark plans in all 34 regions in 2016; three sponsors (Aetna, CVS Health, and Humana) offer

benchmark plans in at least 33 regions.

In 2015, about 70 percent of LIS enrollees

in PDPs are in plans operated by just four

plan sponsors (CVS Health, Humana,

UnitedHealthcare, and Cigna) (Figure

15). The first two of these sponsors offer

PDPs that qualify as benchmark plans in at

least 32 of the 34 PDP regions in 2016. By

contrast, UnitedHealth offers PDPs that

qualify as premium-free in 15 regions in

2016, down from 33 in 2015. Cigna offers

PDPs that qualify as premium-free in 12

regions in 2016, down from 23 in 2015.

Over half of the LIS beneficiaries projected

to pay premiums are currently enrolled in

UnitedHealth or Cigna PDPs.

The LIS enrollees in PDPs offered by these sponsors are split between premium-free benchmark plans and

other plans operated by these sponsors. For example, 64 percent of UnitedHealthcare’s LIS enrollees are in

non-benchmark PDPs and thus pay premiums of $21.06 on average. Many of them are in the AARP

MedicareRx Preferred PDP, which qualified as a benchmark PDP in the program’s earlier years.

Figure 15Figure 15

27

31

33

7

20

34 34

32

30

25

10

22

28

0

25

9

15

3

27

22

28

34

23

17

28

34

4

21

30

34

30

21

31

34 34

27

32

34

33

23

32

33

15

12

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

NOTE: PDP is prescription drug plan.SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2006-2016 PDP landscape source files.

Availability of Benchmark Plans Offered by Four Major Part D Organizations Across the 34 PDP Regions, 2006-2016

Humana CignaUnitedHealth

Number of PDP regions (out of 34):

CVS Health1,265,000 LIS enrollees

in 20152,210,000 LIS enrollees

in 2015877,000 LIS enrollees

in 20151,258,000 LIS enrollees

in 2015

This review of the Part D plan landscape for 2016 and changes over time indicates that most PDP enrollees can

expect to see some changes in their prescription drug coverage and costs in 2016. For most enrollees,

premiums are projected to be higher in 2016 than in 2015, and many will also see higher deductibles and more

cost-sharing tiers with coinsurance. LIS enrollees will have fewer PDP options available at a zero premium, and

many be reassigned to different plans or will need to switch to a different plan to continue without a premium.

Beneficiaries have options during open enrollment to select plans that better meet their needs, including plans

with lower premiums. Although premiums tend to be the most visible feature when comparing plans,

beneficiaries need to consider other factors, especially whether their drugs are on a plan’s formulary, whether

their usual pharmacy offers preferred cost sharing, and the total out-of-pocket costs (including both premiums,

deductibles, and cost sharing) for coverage of their prescription drug needs.

Changes in Part D plan costs and benefit design from one year to the next have been a defining featuring of the

program since its beginning. The reduced number of PDPs for 2016 could make the process of comparing and

reviewing plan options a little easier for beneficiaries to undertake during the open enrollment period, but the

more than two dozen PDP options in each region may still discourage many from reevaluating their choices.

While the annual enrollment period is the best opportunity for people on Medicare to evaluate their plan

options and make changes, our analysis of plan switching by PDP enrollees not receiving the LIS showed that

about 87 percent stayed in the same plan in annual enrollment periods between 2006 and 2010. Even when

they were projected to face large premium increases, a majority of PDP enrollees stayed in the same plan from

one year to the next. Among LIS enrollees, although many are reassigned each year to new plans by CMS, few

(14 percent) of those not eligible for reassignment by CMS and projected to pay a premium switched to new

plans in 2010. Finding ways to get more Part D enrollees engaged in comparing and reviewing plans and

making changes that could save them money remains an ongoing challenge for CMS and policymakers.

NOTE: PDP is prescription drug plan. Analysis for 2016 includes 91 plans under CMS sanction and closed to new enrollees as of September 2015. SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS PDP crosswalk and landscape source files.

NOTE: PDP is prescription drug plan. Analysis for 2016 includes 91 plans under CMS sanction and closed to new enrollees as of September 2015. Average monthly premium is weighted by 2015 enrollments for the region in which the state is located. Terminated plans are excluded in calculation of premium change. SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2015-2016 PDP crosswalk and landscape source files.

NOTE: Benchmark plans are not designated (N/A) in the territories because low-income beneficiaries residing in the territories are not eligible for the low-income subsidy. Analysis for 2016 includes 91 plans under CMS sanction and closed to new enrollees as of September 2015. SOURCE: Georgetown/Kaiser Family Foundation analysis of CMS 2006-2016 PDP landscape source files.

Among the 31 new PDPs in the market, 21 are offered by sponsors totally new to the program: Magellan Rx

America (20 PDPs in 20 regions) and QualChoice Advantage (1 PDP in Arkansas). The other new PDPs are

additional offerings in a few regions by three national or near-national plan sponsors (EnvisionRxPlus,

Symphonix Heath, and WellCare).

Four firms that offer PDPs on a national or near-national basis are eliminating one of the PDPs they offer in

all or most regions. Aetna continued consolidating the PDPs it acquired from Coventry and now sponsors

three PDPs instead of four, eliminating the Aetna Medicare Rx Premier PDP (42,000 enrollees across all

regions). Two of its three offerings in each region are marketed under the First Health name. Cigna, after

consolidating PDPs from its acquisition of HealthSpring, is eliminating one of its three PDPs (Cigna-

HealthSpring Rx Secure-Max PDP with 22,000 enrollees). Express Scripts is eliminating the SmartD Rx

Saver PDPs it acquired in 2014 (73,000 enrollees), leaving only two PDPs per region. Finally, TransAmerica

eliminated its MedicareRx Choice PDPs (20,000 enrollees), leaving it with just a single PDP per region (and

also dropped all PDPs in three regions, affecting another 2,000 enrollees).

Three plan sponsors, each operating a single PDP in just one region, left the program completely: Alliance

Medicare RX PDP, Colorado Access Vista Medicare PDP, Health Alliance Medicare Prescription Plan - Basic

PDP. Each PDP had about 1,000 enrollees.

Four other plan sponsors (EnvisionRxPlus, MedicareBlue Rx, SmartSaver Rx, and United American) made

small adjustments to their offerings. The decision by Blue Cross Blue Shield plans in the upper Midwest

region to drop their Value Plus PDP will affect about 100,000 enrollees, but the other changes have much

smaller effects.

$5,100 $5,451

$5,726

$6,154 $6,440 $6,484

$6,730 $6,955

$6,691 $7,062

$7,515

$3,600 $3,850

$4,050 $4,350

$4,550 $4,550 $4,700 $4,750

$4,550 $4,700

$4,850

$2,250 $2,400 $2,510

$2,700 $2,830 $2,840 $2,930 $2,970 $2,850 $2,960 $3,310

$250 $265 $275 $295 $310 $310 $320 $325 $310 $320 $360

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Catastrophic Limit

Initial Coverage Limit

Deductible

NOTE: Estimates are rounded to nearest whole dollar. SOURCE: Data from the Centers for Medicare & Medicaid Services.

True Out-of-Pocket Spending (TrOOP)

1 These enrollment counts include nearly 7 million Part D enrollees in employer-only plans, not otherwise analyzed for this spotlight.

2 Centers for Medicare and Medicaid Services, “Medicare Advantage Premiums Remain Stable; Enrollment at All-Time High,” September 21, 2015; 2016 PDP, MA, and SNP Landscape Source Files and related files are available at http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/.

3 For analysis of the 2015 Part D marketplace and ten-year trends, see Jack Hoadley, Juliette Cubanski, and Tricia Neuman, "Medicare Part D at Ten Years: The 2015 Marketplace and Key Trends, 2006-2015," Kaiser Family Foundation, October 2015, available at http://kff.org/medicare/report/medicare-part-d-at-ten-years-the-2015-marketplace-and-key-trends-2006-2015/; analysis of the Part D marketplace for earlier years is available at http://kff.org/.

4 The average is weighted by enrollment.

5 Gretchen Jacobson, Anthony Damico, and Tricia Neuman, “What’s In and What’s Out? Medicare Advantage Market Entries and Exits for 2016,” Kaiser Family Foundation, October 2016.

6 In addition, two PDPs offered by First Health (Aetna) changed contract numbers.

7 Based on authors' analysis using the CMS 2016 Part D Crosswalk file.

8 During 2015, the average premium continued to drop, most likely due to plan elections by newly eligible beneficiaries, who are likely to enroll in plans with below-average premiums. The average PDP premium fell from $37.20 in February to $37.02 in April to $36.68 in September, a net drop of 1 percent in seven months.

9 The average premium will increase from $28.18 in 2015 to $30.41 in 2016 for basic-benefit PDPs and will increase from $47.15 to $55.06 for enhanced-benefit PDPs. Enrollees in 37 PDPs will switch from enhanced to basic, but excluding them does not affect the rates of increase.

10 CMS, “Medicare Prescription Drug Premiums Projected to Remain Stable”, available at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-07-29.html.

11 Jack Hoadley, Juliette Cubanski, and Tricia Neuman, "Medicare Part D at Ten Years: The 2015 Marketplace and Key Trends, 2006-2015," Kaiser Family Foundation, October 2015, available at http://kff.org/medicare/report/medicare-part-d-at-ten-years-the-2015-marketplace-and-key-trends-2006-2015/.

12 Centers for Medicare & Medicaid Services, “Annual Release of Part D National Average Bid Amount and Other Part C & D Bid Related Information,” July 29, 2015.

13 Juliette Cubanski and Tricia Neuman, “Medicare's Income-Related Premiums: A Data Note,” June 2015, available at http://kff.org/medicare/issue-brief/medicares-income-related-premiums-a-data-note/.

14 These calculations are made from the Plan Finder for one region and cover only national and near-national plans.

15 This amount corresponds to the estimated catastrophic coverage limit for non-Low-Income Subsidy enrollees ($7,063 for LIS enrollees), which corresponds to True Out-of-Pocket (TrOOP) spending of $4,850 (the amount used to determine when an enrollee reaches the catastrophic coverage threshold).

16 Plans qualifying through the de minimis policy are eligible for new enrollees, but will not receive auto-assigned enrollees.

17 Estimates for the total number of beneficiaries subject to paying a premium are based on plan data from the landscape and crosswalk files, together with CMS enrollment reports. The number to be reassigned will be released by CMS in November or December 2015.

18 These counts of benchmark plans include those designated as de minimis plans, which will not receive auto-assigned enrollees.

19 Jack Hoadley, Elizabeth Hargrave, Laura Summer, Juliette Cubanski, and Tricia Neuman, “To Switch or Not to Switch: Are Medicare Beneficiaries Switching Drug Plans To Save Money?” Kaiser Family Foundation, October 2013, available at http://kff.org/medicare/issue-brief/to-switch-or-not-to-switch-are-medicare-beneficiaries-switching-drug-plans-to-save-money/.

20 Jack Hoadley, Laura Summer, Elizabeth Hargrave, Samuel Stromberg, Juliette Cubanski, and Tricia Neuman, “To Switch or Be Switched: Examining Changes in Drug Plan Enrollment among Medicare Part D Low-Income Subsidy Beneficiaries” Kaiser Family Foundation, July 2015, available at http://kff.org/medicare/report/to-switch-or-be-switched-examining-changes-in-drug-plan-enrollment-among-medicare-part-d-low-income-subsidy-enrollees/.

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